BOARDING HOME ADMISSION AGREEMENT ATTESTATION
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| |PRIVATE DUTY NURSING PRE-CONTRACT EDUCATION ATTESTATION |
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|Instructions for Completing Attestation: |
|Review the Pre-Contract Education PowerPoint and all referenced documents to ensure compliance with applicable requirements. |
|Complete, sign and date a single attestation form |
|PDN applications will not be processed without a signed attestation form. |
| |
|Please address each statement below. |
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|I have reviewed WAC 388-106-1000 through 388-106-1055. | |Yes |
| |
|I have reviewed Ch. 25 of the Long Term Care Manual. | |Yes |
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|I have reviewed the Pre-Contract Provider Education PowerPoint and understand the concepts discussed within. | |Yes |
|PLEASE READ CAREFULLY AND SIGN |
|I declare that the statements above are true. |
|SIGNATURE |DATE |
| | |
|PRINTED NAME |TELEPHONE NUMBER |
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|DBA |
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